|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 60687-184-11
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| 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: EPIC Health Plan Commercial |
$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: 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 60687-184-57
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| 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 |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.48
|
| Rate for Payer: Blue Distinction Transplant |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| 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 Media |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.60
|
| 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: 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
|
| 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
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 33342-298-09
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Blue Distinction Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Media |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 0832-1113-60
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| 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: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| 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
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$8.90
|
|
|
Service Code
|
NDC 0456-3205-60
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$7.56 |
| Rate for Payer: Blue Shield of California Commercial |
$6.34
|
| Rate for Payer: Blue Shield of California EPN |
$4.56
|
| Rate for Payer: Cash Price |
$4.01
|
| Rate for Payer: Cigna of CA HMO |
$6.23
|
| Rate for Payer: Cigna of CA PPO |
$6.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.56
|
| Rate for Payer: Galaxy Health WC |
$7.56
|
| Rate for Payer: Global Benefits Group Commercial |
$5.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$7.12
|
| Rate for Payer: Networks By Design Commercial |
$5.78
|
| Rate for Payer: Prime Health Services Commercial |
$7.56
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-57
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| 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: EPIC Health Plan Commercial |
$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: 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
|
$0.22
|
|
|
Service Code
|
NDC 0832-1112-60
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| 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 |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Distinction Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| 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 Media |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| 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
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 0904-6505-61
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.44
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.44
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 0832-1112-60
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| 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: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| 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
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$8.90
|
|
|
Service Code
|
NDC 0456-3205-60
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$7.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.30
|
| Rate for Payer: Blue Distinction Transplant |
$5.34
|
| Rate for Payer: Blue Shield of California Commercial |
$6.56
|
| Rate for Payer: Blue Shield of California EPN |
$5.20
|
| Rate for Payer: Cash Price |
$4.01
|
| Rate for Payer: Cigna of CA HMO |
$6.23
|
| Rate for Payer: Cigna of CA PPO |
$6.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.56
|
| Rate for Payer: Dignity Health Media |
$7.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.56
|
| Rate for Payer: Galaxy Health WC |
$7.56
|
| Rate for Payer: Global Benefits Group Commercial |
$5.34
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$7.12
|
| Rate for Payer: Networks By Design Commercial |
$5.78
|
| Rate for Payer: Prime Health Services Commercial |
$7.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Other HMO |
$4.45
|
| Rate for Payer: United Healthcare HMO Rider |
$4.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.56
|
| Rate for Payer: Vantage Medical Group Senior |
$7.56
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-57
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| 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 |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Distinction Transplant |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| 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 Media |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.44
|
| 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: 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
|
| 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
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-11
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| 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: EPIC Health Plan Commercial |
$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: 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
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-11
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| 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 |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Distinction Transplant |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| 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 Media |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.44
|
| 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: 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
|
| 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
|
$0.52
|
|
|
Service Code
|
NDC 0904-6505-61
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: Blue Distinction Transplant |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Media |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.44
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO |
$0.26
|
| Rate for Payer: United Healthcare HMO Rider |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Vantage Medical Group Senior |
$0.44
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
IP
|
$505.37
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
NDG208665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$121.29 |
| Max. Negotiated Rate |
$429.56 |
| Rate for Payer: Blue Shield of California Commercial |
$359.82
|
| Rate for Payer: Blue Shield of California EPN |
$258.75
|
| Rate for Payer: Cash Price |
$227.42
|
| Rate for Payer: Cigna of CA HMO |
$353.76
|
| Rate for Payer: Cigna of CA PPO |
$353.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$202.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$202.15
|
| Rate for Payer: Galaxy Health WC |
$429.56
|
| Rate for Payer: Global Benefits Group Commercial |
$303.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$337.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$192.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.29
|
| Rate for Payer: Multiplan Commercial |
$404.30
|
| Rate for Payer: Networks By Design Commercial |
$252.68
|
| Rate for Payer: Prime Health Services Commercial |
$429.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$190.83
|
| Rate for Payer: United Healthcare All Other HMO |
$186.38
|
| Rate for Payer: United Healthcare HMO Rider |
$182.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$166.77
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
OP
|
$505.37
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
NDG208665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$121.29 |
| Max. Negotiated Rate |
$1,497.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,497.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$429.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$277.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$277.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$408.44
|
| Rate for Payer: Blue Distinction Transplant |
$303.22
|
| Rate for Payer: Blue Shield of California Commercial |
$372.46
|
| Rate for Payer: Blue Shield of California EPN |
$214.95
|
| Rate for Payer: Cash Price |
$227.42
|
| Rate for Payer: Cash Price |
$227.42
|
| Rate for Payer: Cigna of CA HMO |
$353.76
|
| Rate for Payer: Cigna of CA PPO |
$353.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$429.56
|
| Rate for Payer: Dignity Health Media |
$429.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$429.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$202.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$202.15
|
| Rate for Payer: Galaxy Health WC |
$429.56
|
| Rate for Payer: Global Benefits Group Commercial |
$303.22
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$379.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$337.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$432.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.29
|
| Rate for Payer: Multiplan Commercial |
$404.30
|
| Rate for Payer: Networks By Design Commercial |
$252.68
|
| Rate for Payer: Prime Health Services Commercial |
$429.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$303.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$303.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$252.68
|
| Rate for Payer: United Healthcare All Other HMO |
$252.68
|
| Rate for Payer: United Healthcare HMO Rider |
$252.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$252.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$429.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$429.56
|
| Rate for Payer: Vantage Medical Group Senior |
$429.56
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
IP
|
$354.57
|
|
|
Service Code
|
NDC 58160-827-03
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.10 |
| Max. Negotiated Rate |
$301.38 |
| Rate for Payer: Blue Shield of California Commercial |
$252.45
|
| Rate for Payer: Blue Shield of California EPN |
$181.54
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cigna of CA HMO |
$248.20
|
| Rate for Payer: Cigna of CA PPO |
$248.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$141.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$141.83
|
| Rate for Payer: Galaxy Health WC |
$301.38
|
| Rate for Payer: Global Benefits Group Commercial |
$212.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$236.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$135.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.10
|
| Rate for Payer: Multiplan Commercial |
$283.66
|
| Rate for Payer: Networks By Design Commercial |
$177.28
|
| Rate for Payer: Prime Health Services Commercial |
$301.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$133.89
|
| Rate for Payer: United Healthcare All Other HMO |
$130.77
|
| Rate for Payer: United Healthcare HMO Rider |
$127.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$117.01
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
OP
|
$354.57
|
|
|
Service Code
|
NDC 58160-827-30
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.10 |
| Max. Negotiated Rate |
$301.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$232.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$301.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$195.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$195.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$211.25
|
| Rate for Payer: Blue Distinction Transplant |
$212.74
|
| Rate for Payer: Blue Shield of California Commercial |
$261.32
|
| Rate for Payer: Blue Shield of California EPN |
$207.07
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cigna of CA HMO |
$248.20
|
| Rate for Payer: Cigna of CA PPO |
$248.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$301.38
|
| Rate for Payer: Dignity Health Media |
$301.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$301.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$141.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$141.83
|
| Rate for Payer: Galaxy Health WC |
$301.38
|
| Rate for Payer: Global Benefits Group Commercial |
$212.74
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$265.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$236.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$135.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.10
|
| Rate for Payer: Multiplan Commercial |
$283.66
|
| Rate for Payer: Networks By Design Commercial |
$177.28
|
| Rate for Payer: Prime Health Services Commercial |
$301.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$212.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$212.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$177.28
|
| Rate for Payer: United Healthcare All Other HMO |
$177.28
|
| Rate for Payer: United Healthcare HMO Rider |
$177.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$177.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$301.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$301.38
|
| Rate for Payer: Vantage Medical Group Senior |
$301.38
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
IP
|
$354.57
|
|
|
Service Code
|
NDC 58160-827-30
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.10 |
| Max. Negotiated Rate |
$301.38 |
| Rate for Payer: Blue Shield of California Commercial |
$252.45
|
| Rate for Payer: Blue Shield of California EPN |
$181.54
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cigna of CA HMO |
$248.20
|
| Rate for Payer: Cigna of CA PPO |
$248.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$141.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$141.83
|
| Rate for Payer: Galaxy Health WC |
$301.38
|
| Rate for Payer: Global Benefits Group Commercial |
$212.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$236.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$135.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.10
|
| Rate for Payer: Multiplan Commercial |
$283.66
|
| Rate for Payer: Networks By Design Commercial |
$177.28
|
| Rate for Payer: Prime Health Services Commercial |
$301.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$133.89
|
| Rate for Payer: United Healthcare All Other HMO |
$130.77
|
| Rate for Payer: United Healthcare HMO Rider |
$127.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$117.01
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
OP
|
$354.57
|
|
|
Service Code
|
NDC 58160-827-03
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.10 |
| Max. Negotiated Rate |
$301.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$232.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$301.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$195.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$195.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$211.25
|
| Rate for Payer: Blue Distinction Transplant |
$212.74
|
| Rate for Payer: Blue Shield of California Commercial |
$261.32
|
| Rate for Payer: Blue Shield of California EPN |
$207.07
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cigna of CA HMO |
$248.20
|
| Rate for Payer: Cigna of CA PPO |
$248.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$301.38
|
| Rate for Payer: Dignity Health Media |
$301.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$301.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$141.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$141.83
|
| Rate for Payer: Galaxy Health WC |
$301.38
|
| Rate for Payer: Global Benefits Group Commercial |
$212.74
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$265.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$236.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$135.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.10
|
| Rate for Payer: Multiplan Commercial |
$283.66
|
| Rate for Payer: Networks By Design Commercial |
$177.28
|
| Rate for Payer: Prime Health Services Commercial |
$301.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$212.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$212.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$177.28
|
| Rate for Payer: United Healthcare All Other HMO |
$177.28
|
| Rate for Payer: United Healthcare HMO Rider |
$177.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$177.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$301.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$301.38
|
| Rate for Payer: Vantage Medical Group Senior |
$301.38
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]
|
Facility
|
IP
|
$177.29
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
ERX101034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.55 |
| Max. Negotiated Rate |
$150.70 |
| Rate for Payer: Blue Shield of California Commercial |
$126.23
|
| Rate for Payer: Blue Shield of California Commercial |
$217.02
|
| Rate for Payer: Blue Shield of California EPN |
$90.77
|
| Rate for Payer: Blue Shield of California EPN |
$156.06
|
| Rate for Payer: Cash Price |
$79.78
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cigna of CA HMO |
$124.10
|
| Rate for Payer: Cigna of CA HMO |
$213.36
|
| Rate for Payer: Cigna of CA PPO |
$213.36
|
| Rate for Payer: Cigna of CA PPO |
$124.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$121.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$70.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$121.92
|
| Rate for Payer: Galaxy Health WC |
$150.70
|
| Rate for Payer: Galaxy Health WC |
$259.08
|
| Rate for Payer: Global Benefits Group Commercial |
$182.88
|
| Rate for Payer: Global Benefits Group Commercial |
$106.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$203.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$118.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$67.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$116.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.15
|
| Rate for Payer: Multiplan Commercial |
$141.83
|
| Rate for Payer: Multiplan Commercial |
$243.84
|
| Rate for Payer: Networks By Design Commercial |
$88.64
|
| Rate for Payer: Networks By Design Commercial |
$152.40
|
| Rate for Payer: Prime Health Services Commercial |
$150.70
|
| Rate for Payer: Prime Health Services Commercial |
$259.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$66.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$115.09
|
| Rate for Payer: United Healthcare All Other HMO |
$65.38
|
| Rate for Payer: United Healthcare All Other HMO |
$112.41
|
| Rate for Payer: United Healthcare HMO Rider |
$63.97
|
| Rate for Payer: United Healthcare HMO Rider |
$109.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$58.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$100.58
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]
|
Facility
|
OP
|
$177.29
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
ERX101034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.55 |
| Max. Negotiated Rate |
$1,052.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,052.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,052.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$259.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$150.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$97.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$167.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$167.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$97.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$161.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$161.78
|
| Rate for Payer: Blue Distinction Transplant |
$106.37
|
| Rate for Payer: Blue Distinction Transplant |
$182.88
|
| Rate for Payer: Blue Shield of California Commercial |
$130.66
|
| Rate for Payer: Blue Shield of California Commercial |
$224.64
|
| Rate for Payer: Blue Shield of California EPN |
$153.91
|
| Rate for Payer: Blue Shield of California EPN |
$153.91
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cash Price |
$79.78
|
| Rate for Payer: Cash Price |
$79.78
|
| Rate for Payer: Cigna of CA HMO |
$124.10
|
| Rate for Payer: Cigna of CA HMO |
$213.36
|
| Rate for Payer: Cigna of CA PPO |
$124.10
|
| 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 |
$150.70
|
| Rate for Payer: Dignity Health Media |
$259.08
|
| Rate for Payer: Dignity Health Media |
$150.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$150.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$259.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$121.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$70.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$121.92
|
| Rate for Payer: Galaxy Health WC |
$150.70
|
| Rate for Payer: Galaxy Health WC |
$259.08
|
| Rate for Payer: Global Benefits Group Commercial |
$182.88
|
| Rate for Payer: Global Benefits Group Commercial |
$106.37
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$228.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$132.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$203.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$118.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$289.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$289.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.55
|
| Rate for Payer: Multiplan Commercial |
$243.84
|
| Rate for Payer: Multiplan Commercial |
$141.83
|
| Rate for Payer: Networks By Design Commercial |
$88.64
|
| Rate for Payer: Networks By Design Commercial |
$152.40
|
| Rate for Payer: Prime Health Services Commercial |
$259.08
|
| Rate for Payer: Prime Health Services Commercial |
$150.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$182.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$106.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$182.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$106.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$88.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$152.40
|
| Rate for Payer: United Healthcare All Other HMO |
$152.40
|
| Rate for Payer: United Healthcare All Other HMO |
$88.64
|
| Rate for Payer: United Healthcare HMO Rider |
$152.40
|
| Rate for Payer: United Healthcare HMO Rider |
$88.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$88.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$152.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$150.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$259.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$150.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$259.08
|
| Rate for Payer: Vantage Medical Group Senior |
$259.08
|
| Rate for Payer: Vantage Medical Group Senior |
$150.70
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP (PF) 4 MCG/0.5 ML INTRAMUSCULAR SOLUTION [40540]
|
Facility
|
OP
|
$355.20
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
1721125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.25 |
| Max. Negotiated Rate |
$1,052.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,052.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$301.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$195.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$195.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$161.78
|
| Rate for Payer: Blue Distinction Transplant |
$213.12
|
| Rate for Payer: Blue Shield of California Commercial |
$261.78
|
| Rate for Payer: Blue Shield of California EPN |
$153.91
|
| Rate for Payer: Cash Price |
$159.84
|
| Rate for Payer: Cash Price |
$159.84
|
| Rate for Payer: Cigna of CA HMO |
$248.64
|
| Rate for Payer: Cigna of CA PPO |
$248.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$301.92
|
| Rate for Payer: Dignity Health Media |
$301.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$301.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$142.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$142.08
|
| Rate for Payer: Galaxy Health WC |
$301.92
|
| Rate for Payer: Global Benefits Group Commercial |
$213.12
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$266.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$236.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$289.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.25
|
| Rate for Payer: Multiplan Commercial |
$284.16
|
| Rate for Payer: Networks By Design Commercial |
$177.60
|
| Rate for Payer: Prime Health Services Commercial |
$301.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$213.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$213.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$177.60
|
| Rate for Payer: United Healthcare All Other HMO |
$177.60
|
| Rate for Payer: United Healthcare HMO Rider |
$177.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$177.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$301.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$301.92
|
| Rate for Payer: Vantage Medical Group Senior |
$301.92
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP (PF) 4 MCG/0.5 ML INTRAMUSCULAR SOLUTION [40540]
|
Facility
|
IP
|
$355.20
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
1721125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.25 |
| Max. Negotiated Rate |
$301.92 |
| Rate for Payer: Blue Shield of California Commercial |
$252.90
|
| Rate for Payer: Blue Shield of California EPN |
$181.86
|
| Rate for Payer: Cash Price |
$159.84
|
| Rate for Payer: Cigna of CA HMO |
$248.64
|
| Rate for Payer: Cigna of CA PPO |
$248.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$142.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$142.08
|
| Rate for Payer: Galaxy Health WC |
$301.92
|
| Rate for Payer: Global Benefits Group Commercial |
$213.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$236.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$135.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.25
|
| Rate for Payer: Multiplan Commercial |
$284.16
|
| Rate for Payer: Networks By Design Commercial |
$177.60
|
| Rate for Payer: Prime Health Services Commercial |
$301.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$134.12
|
| Rate for Payer: United Healthcare All Other HMO |
$131.00
|
| Rate for Payer: United Healthcare HMO Rider |
$128.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$117.22
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
|
Facility
|
IP
|
$12,621.72
|
|
|
Service Code
|
APR-DRG 5323
|
| Min. Negotiated Rate |
$9,682.19 |
| Max. Negotiated Rate |
$12,621.72 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,682.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,621.72
|
|
