|
MINOCYCLINE 100 MG CAPSULE [5110]
|
Facility
OP
|
$1.32
|
|
|
Service Code
|
NDC 60687-336-65
|
| Hospital Charge Code |
1710661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: BCBS Transplant Transplant |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.12
|
| Rate for Payer: Dignity Health Media |
$1.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.53
|
| Rate for Payer: Galaxy Health WC |
$1.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.06
|
| Rate for Payer: Networks By Design Commercial |
$0.86
|
| Rate for Payer: Prime Health Services Commercial |
$1.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Vantage Medical Group Senior |
$1.12
|
|
|
MINOCYCLINE 100 MG CAPSULE [5110]
|
Facility
IP
|
$0.67
|
|
|
Service Code
|
NDC 65862-211-50
|
| Hospital Charge Code |
1710661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
|
|
MINOCYCLINE 100 MG INTRAVENOUS SOLUTION [10612]
|
Facility
IP
|
$286.80
|
|
|
Service Code
|
NDC 70842-160-01
|
| Hospital Charge Code |
ERX10612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.83 |
| Max. Negotiated Rate |
$243.78 |
| Rate for Payer: Blue Shield of California Commercial |
$204.20
|
| Rate for Payer: Blue Shield of California EPN |
$146.84
|
| Rate for Payer: Cash Price |
$129.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$114.72
|
| Rate for Payer: Galaxy Health WC |
$243.78
|
| Rate for Payer: Global Benefits Group Commercial |
$172.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$191.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$109.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.83
|
| Rate for Payer: Multiplan Commercial |
$229.44
|
| Rate for Payer: Networks By Design Commercial |
$186.42
|
| Rate for Payer: Prime Health Services Commercial |
$243.78
|
|
|
MINOCYCLINE 100 MG INTRAVENOUS SOLUTION [10612]
|
Facility
IP
|
$286.80
|
|
|
Service Code
|
NDC 70842-160-10
|
| Hospital Charge Code |
ERX10612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.83 |
| Max. Negotiated Rate |
$243.78 |
| Rate for Payer: Blue Shield of California Commercial |
$204.20
|
| Rate for Payer: Blue Shield of California EPN |
$146.84
|
| Rate for Payer: Cash Price |
$129.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$114.72
|
| Rate for Payer: Galaxy Health WC |
$243.78
|
| Rate for Payer: Global Benefits Group Commercial |
$172.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$191.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$109.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.83
|
| Rate for Payer: Multiplan Commercial |
$229.44
|
| Rate for Payer: Networks By Design Commercial |
$186.42
|
| Rate for Payer: Prime Health Services Commercial |
$243.78
|
|
|
MINOCYCLINE 100 MG INTRAVENOUS SOLUTION [10612]
|
Facility
OP
|
$286.80
|
|
|
Service Code
|
NDC 70842-160-01
|
| Hospital Charge Code |
ERX10612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.83 |
| Max. Negotiated Rate |
$243.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$188.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$243.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$157.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$157.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$170.88
|
| Rate for Payer: BCBS Transplant Transplant |
$172.08
|
| Rate for Payer: Blue Shield of California Commercial |
$211.37
|
| Rate for Payer: Blue Shield of California EPN |
$167.49
|
| Rate for Payer: Cash Price |
$129.06
|
| Rate for Payer: Cash Price |
$129.06
|
| Rate for Payer: Cigna of CA HMO |
$183.55
|
| Rate for Payer: Cigna of CA PPO |
$212.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$243.78
|
| Rate for Payer: Dignity Health Media |
$243.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$243.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$114.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$114.72
|
| Rate for Payer: Galaxy Health WC |
$243.78
|
| Rate for Payer: Global Benefits Group Commercial |
$172.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$215.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$191.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$109.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.83
|
| Rate for Payer: Multiplan Commercial |
$229.44
|
| Rate for Payer: Networks By Design Commercial |
$186.42
|
| Rate for Payer: Prime Health Services Commercial |
$243.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$172.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$172.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$143.40
|
| Rate for Payer: United Healthcare All Other HMO |
$143.40
|
| Rate for Payer: United Healthcare HMO Rider |
$143.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$143.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$243.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$243.78
|
| Rate for Payer: Vantage Medical Group Senior |
$243.78
|
|
|
MINOCYCLINE 100 MG INTRAVENOUS SOLUTION [10612]
|
Facility
OP
|
$286.80
|
|
|
Service Code
|
NDC 70842-160-10
|
| Hospital Charge Code |
ERX10612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.83 |
| Max. Negotiated Rate |
$243.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$188.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$243.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$157.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$157.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$170.88
|
| Rate for Payer: BCBS Transplant Transplant |
$172.08
|
| Rate for Payer: Blue Shield of California Commercial |
$211.37
|
| Rate for Payer: Blue Shield of California EPN |
$167.49
|
| Rate for Payer: Cash Price |
$129.06
|
| Rate for Payer: Cash Price |
$129.06
|
| Rate for Payer: Cigna of CA HMO |
$183.55
|
| Rate for Payer: Cigna of CA PPO |
$212.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$243.78
|
| Rate for Payer: Dignity Health Media |
$243.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$243.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$114.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$114.72
|
| Rate for Payer: Galaxy Health WC |
$243.78
|
| Rate for Payer: Global Benefits Group Commercial |
$172.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$215.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$191.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$109.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.83
|
| Rate for Payer: Multiplan Commercial |
$229.44
|
| Rate for Payer: Networks By Design Commercial |
$186.42
|
| Rate for Payer: Prime Health Services Commercial |
$243.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$172.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$172.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$143.40
|
| Rate for Payer: United Healthcare All Other HMO |
$143.40
|
| Rate for Payer: United Healthcare HMO Rider |
$143.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$143.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$243.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$243.78
|
| Rate for Payer: Vantage Medical Group Senior |
$243.78
|
|
|
MINOCYCLINE 50 MG CAPSULE [5111]
|
Facility
OP
|
$0.32
|
|
|
Service Code
|
NDC 0591-5694-01
|
| Hospital Charge Code |
1710649
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: BCBS Transplant Transplant |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Media |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
MINOCYCLINE 50 MG CAPSULE [5111]
|
Facility
IP
|
$0.32
|
|
|
Service Code
|
NDC 0591-5694-01
|
| Hospital Charge Code |
1710649
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
|
|
MINOXIDIL 10 MG TABLET [5114]
|
Facility
IP
|
$0.55
|
|
|
Service Code
|
CPT S0139
|
| Hospital Charge Code |
1710559
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.54
|
| Rate for Payer: Cigna of CA PPO |
$0.54
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$0.65
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.65
|
|
|
MINOXIDIL 10 MG TABLET [5114]
|
Facility
OP
|
$0.56
|
|
|
Service Code
|
CPT S0139
|
| Hospital Charge Code |
1710559
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.12
|
| Rate for Payer: BCBS Transplant Transplant |
$0.34
|
| Rate for Payer: BCBS Transplant Transplant |
$0.46
|
| Rate for Payer: BCBS Transplant Transplant |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.54
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Media |
$0.48
|
| Rate for Payer: Dignity Health Media |
$0.47
|
| Rate for Payer: Dignity Health Media |
$0.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.31
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Galaxy Health WC |
$0.65
|
| Rate for Payer: Global Benefits Group Commercial |
$0.46
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.41
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.42
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.65
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.46
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.34
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO |
$0.39
|
| Rate for Payer: United Healthcare All Other HMO |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO |
$0.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.65
|
|
|
MINOXIDIL 2.5 MG TABLET [5115]
|
Facility
OP
|
$0.25
|
|
|
Service Code
|
CPT S0139
|
| Hospital Charge Code |
1710553
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.12
|
| Rate for Payer: BCBS Transplant Transplant |
$0.15
|
| Rate for Payer: BCBS Transplant Transplant |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.44
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Media |
$0.54
|
| Rate for Payer: Dignity Health Media |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.47
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.41
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare HMO Rider |
$0.32
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
MINOXIDIL 2.5 MG TABLET [5115]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
CPT S0139
|
| Hospital Charge Code |
1710553
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.44
|
| Rate for Payer: Cigna of CA PPO |
$0.44
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.41
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
OP
|
$17.88
|
|
|
Service Code
|
NDC 0469-2601-30
|
| Hospital Charge Code |
ERX196915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$15.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.65
|
| Rate for Payer: BCBS Transplant Transplant |
$10.73
|
| Rate for Payer: Blue Shield of California Commercial |
$13.18
|
| Rate for Payer: Blue Shield of California EPN |
$10.44
|
| Rate for Payer: Cash Price |
$8.05
|
| Rate for Payer: Cigna of CA HMO |
$12.52
|
| Rate for Payer: Cigna of CA PPO |
$12.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.20
|
| Rate for Payer: Dignity Health Media |
$15.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.15
|
| Rate for Payer: Galaxy Health WC |
$15.20
|
| Rate for Payer: Global Benefits Group Commercial |
$10.73
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$13.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.29
|
| Rate for Payer: Multiplan Commercial |
$14.30
|
| Rate for Payer: Networks By Design Commercial |
$11.62
|
| Rate for Payer: Prime Health Services Commercial |
$15.20
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$10.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.94
|
| Rate for Payer: United Healthcare All Other HMO |
$8.94
|
| Rate for Payer: United Healthcare HMO Rider |
$8.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.20
|
| Rate for Payer: Vantage Medical Group Senior |
$15.20
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
IP
|
$17.88
|
|
|
Service Code
|
NDC 0469-2601-30
|
| Hospital Charge Code |
ERX196915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Blue Shield of California Commercial |
$12.73
|
| Rate for Payer: Blue Shield of California EPN |
$9.15
|
| Rate for Payer: Cash Price |
$8.05
|
| Rate for Payer: Cigna of CA HMO |
$12.52
|
| Rate for Payer: Cigna of CA PPO |
$12.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.15
|
| Rate for Payer: Galaxy Health WC |
$15.20
|
| Rate for Payer: Global Benefits Group Commercial |
$10.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.29
|
| Rate for Payer: Multiplan Commercial |
$14.30
|
| Rate for Payer: Networks By Design Commercial |
$11.62
|
| Rate for Payer: Prime Health Services Commercial |
$15.20
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
IP
|
$0.51
|
|
|
Service Code
|
NDC 65862-021-06
|
| Hospital Charge Code |
1711863
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| 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 |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
OP
|
$0.73
|
|
|
Service Code
|
NDC 57237-011-06
|
| Hospital Charge Code |
1711863
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.43
|
| Rate for Payer: BCBS Transplant Transplant |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.51
|
| Rate for Payer: Cigna of CA PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.62
|
| Rate for Payer: Dignity Health Media |
$0.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.62
|
| Rate for Payer: Global Benefits Group Commercial |
$0.44
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.62
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.37
|
| Rate for Payer: United Healthcare All Other HMO |
$0.37
|
| Rate for Payer: United Healthcare HMO Rider |
$0.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Vantage Medical Group Senior |
$0.62
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
IP
|
$0.73
|
|
|
Service Code
|
NDC 57237-011-06
|
| Hospital Charge Code |
1711863
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.51
|
| Rate for Payer: Cigna of CA PPO |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.62
|
| Rate for Payer: Global Benefits Group Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.62
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
OP
|
$0.51
|
|
|
Service Code
|
NDC 65862-021-06
|
| Hospital Charge Code |
1711863
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| 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 |
$0.43
|
| Rate for Payer: Dignity Health Media |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| 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 |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 0904-6519-61
|
| Hospital Charge Code |
1713135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| 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 Media |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| 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
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 13107-031-34
|
| Hospital Charge Code |
1713135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 13107-031-34
|
| Hospital Charge Code |
1713135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: BCBS Transplant Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Media |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 0904-6519-61
|
| Hospital Charge Code |
1713135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| 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: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: 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
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 57664-499-83
|
| Hospital Charge Code |
1713135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 57664-499-83
|
| Hospital Charge Code |
1713135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: BCBS Transplant Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Media |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
OP
|
$0.45
|
|
|
Service Code
|
NDC 13107-003-34
|
| Hospital Charge Code |
1713136
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: BCBS Transplant Transplant |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Media |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
