|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
IP
|
$538.80
|
|
|
Service Code
|
NDC 43598-392-48
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.31 |
| Max. Negotiated Rate |
$457.98 |
| Rate for Payer: Blue Shield of California Commercial |
$383.63
|
| Rate for Payer: Blue Shield of California EPN |
$275.87
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Cigna of CA HMO |
$377.16
|
| Rate for Payer: Cigna of CA PPO |
$377.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$215.52
|
| Rate for Payer: Galaxy Health WC |
$457.98
|
| Rate for Payer: Global Benefits Group Commercial |
$323.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$359.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$205.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$129.31
|
| Rate for Payer: Multiplan Commercial |
$431.04
|
| Rate for Payer: Networks By Design Commercial |
$269.40
|
| Rate for Payer: Prime Health Services Commercial |
$457.98
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
IP
|
$240.00
|
|
|
Service Code
|
NDC 54288-106-01
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Blue Shield of California Commercial |
$170.88
|
| Rate for Payer: Blue Shield of California EPN |
$122.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.60
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
IP
|
$240.00
|
|
|
Service Code
|
NDC 71288-130-15
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Blue Shield of California Commercial |
$170.88
|
| Rate for Payer: Blue Shield of California EPN |
$122.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.60
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
OP
|
$538.80
|
|
|
Service Code
|
NDC 43598-392-48
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.31 |
| Max. Negotiated Rate |
$457.98 |
| Rate for Payer: Aetna of CA HMO/PPO |
$353.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$457.98
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$296.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$296.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$321.02
|
| Rate for Payer: BCBS Transplant Transplant |
$323.28
|
| Rate for Payer: Blue Shield of California Commercial |
$397.10
|
| Rate for Payer: Blue Shield of California EPN |
$314.66
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Cigna of CA HMO |
$377.16
|
| Rate for Payer: Cigna of CA PPO |
$377.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$457.98
|
| Rate for Payer: Dignity Health Media |
$457.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$457.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$215.52
|
| Rate for Payer: Galaxy Health WC |
$457.98
|
| Rate for Payer: Global Benefits Group Commercial |
$323.28
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$404.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$359.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$205.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$129.31
|
| Rate for Payer: Multiplan Commercial |
$431.04
|
| Rate for Payer: Networks By Design Commercial |
$269.40
|
| Rate for Payer: Prime Health Services Commercial |
$457.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$323.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$323.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$269.40
|
| Rate for Payer: United Healthcare All Other HMO |
$269.40
|
| Rate for Payer: United Healthcare HMO Rider |
$269.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$269.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$457.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$457.98
|
| Rate for Payer: Vantage Medical Group Senior |
$457.98
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
OP
|
$240.00
|
|
|
Service Code
|
NDC 71288-130-15
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$157.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$132.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$142.99
|
| Rate for Payer: BCBS Transplant Transplant |
$144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$176.88
|
| Rate for Payer: Blue Shield of California EPN |
$140.16
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Media |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$180.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.60
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$144.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$144.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Other HMO |
$120.00
|
| Rate for Payer: United Healthcare HMO Rider |
$120.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$120.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
OP
|
$240.00
|
|
|
Service Code
|
NDC 71288-132-90
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$157.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$132.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$142.99
|
| Rate for Payer: BCBS Transplant Transplant |
$144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$176.88
|
| Rate for Payer: Blue Shield of California EPN |
$140.16
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Media |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$180.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.60
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$144.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$144.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Other HMO |
$120.00
|
| Rate for Payer: United Healthcare HMO Rider |
$120.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$120.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
OP
|
$240.00
|
|
|
Service Code
|
NDC 54288-109-02
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$157.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$132.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$142.99
|
| Rate for Payer: BCBS Transplant Transplant |
$144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$176.88
|
| Rate for Payer: Blue Shield of California EPN |
$140.16
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Media |
$204.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$180.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.60
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$144.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$144.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Other HMO |
$120.00
|
| Rate for Payer: United Healthcare HMO Rider |
$120.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$120.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
IP
|
$240.00
|
|
|
Service Code
|
NDC 54288-109-02
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Blue Shield of California Commercial |
$170.88
|
| Rate for Payer: Blue Shield of California EPN |
$122.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.60
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
IP
|
$538.80
|
|
|
Service Code
|
NDC 43598-391-50
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.31 |
| Max. Negotiated Rate |
$457.98 |
| Rate for Payer: Blue Shield of California Commercial |
$383.63
|
| Rate for Payer: Blue Shield of California EPN |
$275.87
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Cigna of CA HMO |
$377.16
|
| Rate for Payer: Cigna of CA PPO |
$377.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$215.52
|
| Rate for Payer: Galaxy Health WC |
$457.98
|
| Rate for Payer: Global Benefits Group Commercial |
$323.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$359.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$205.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$129.31
|
| Rate for Payer: Multiplan Commercial |
$431.04
|
| Rate for Payer: Networks By Design Commercial |
$269.40
|
| Rate for Payer: Prime Health Services Commercial |
$457.98
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.26
|
| 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
|
$0.43
|
|
|
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: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| 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: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| 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
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
OP
|
$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: Aetna of CA HMO/PPO |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.48
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.48
|
| 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
|
$0.80
|
|
|
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: 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
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
|
$0.22
|
|
|
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: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| 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 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 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: BCBS Transplant Transplant |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.48
|
| 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 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: Galaxy Health WC |
$0.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: BCBS Transplant 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: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.35
|
| 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 60687-173-57
|
| 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
|
$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: BCBS Transplant Transplant |
$5.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.30
|
| 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$5.34
|
| 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
|
$0.52
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.31
|
| 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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| 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
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
|
|
